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12/ �2804 13:38 9168610-9 SECOR PAGE 63103 <br /> 1 .'14/2p04 12:50 9166;:x11, CASCADEDRILLINbft'� PAGE 02102 <br /> San Joaquin County Envlratirngntal Health Department Unit IV Well Permit Application Supplement <br /> .1013 ADDRESS; 32Q2 W. Hammer Lane St» C on PERMIT SRO: 004040E <br /> LICENSED CONTRACTORS DECLARATION (LCC}) <br /> I hereby V iffn that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Profamlons Code and my license is in full!orae and effect. <br /> License#; 717810 Expiration Date: 1108 <br /> Date: ! _... Conttactor g Qg&ade Qnll'n <br /> Signature' Title'^� • <br /> Printed narne: I)ojl Klui- ch <br /> WORKERS' COMPENSATION DECLARAT10N <br /> I hereby affirm Wer penalty of perjury one of the following declarations: (CHECK ONF) <br /> I have and Vail)maintain a certificate of content to self-insure for workers'compensation, as provided far <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> __X_1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor <br /> Code, <br /> for the perrorntance of the work for which this permit i t issued. My workers' compensation fnsurance <br /> carder and policy numbers are: <br /> Carder: Ala Nation&I Policy Number- <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workars' compensation laws of Cnftmia, and agree that if I <br /> should become subject io the workers'compensation provisions of Section 3700 of the bnr Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Signature: <br /> Date: 5006..- <br /> Printed Name: Qon-t<!nIoqb <br /> WARKINGt FAILURE TO SECURE WORKERS'COMPENSATION COVIERAGE IS UNLAWFUL,AND SHALL SU13JECT <br /> AN EmmOYER To CRIMINAL PENALTIES AND GRIL FINES UP TO ONE 14UMRE D THOUSAND DOLLARS <br /> ( D N DW ION TO THE COST OF <br /> 3706 a THE LABOR COMPENSATION,INTEREST.ATTORNEY'S FUM,AND DAMAGES AS <br /> RRbVT <br /> AU HORIZATI N FOR OT ER THAN C-37 SIGNING PERMIT APPLICATION <br /> 1. (signature of C-57 Iiaefted authorized represenu ve), <br /> fler�aby au horize(print name)__r a 12Lc,55� <br /> to sign thus San Joaquin County wen hermit Application otr my behalf. I undersUnd this atftoplzation i9 VOW for <br /> one(1)year and Is limited to(fie work plan dated on the front page of this application. <br />